The Rationale for Nursing Management - Essay Example

The Rationale for Nursing Management Case I Mrs. Islet Langerhans is 65 years of age and has a PMHx of T2DM. On return to the ward post hemicolectomy she was administered IV infusion of 4% dextrose and 1/5 normal saline at 84mL/h and IV Actrapid insulin infusion. Her BGL ranged from 18-23mmol/L. The reason for raised BGL was her history of T2DM, previous non-compliance with diabetic diet, hypoglycemic medication regimen and use of IV solution containing dextrose on admission. IV solutions containing dextrose should never be administered to a patient with T2DM unless BGL is less than 3mmol/L. The rationale for this is that, in the hyperglycemic state, the body fails to utilize the body glucose as it fails to convert the high glucose to glycogen. Besides the levels of glucose may be low than normal. Therefore, the intervention of infusing with dextrose is needed to prevent the body from turning to the use of ketone bodies, which may predispose to the development of diabetic ketoacidosis. However, this is only appropriate intervention if the body glucose level is less than 3mmol/l (Kable & Bourgeois 2014; p. 61). Therefore, the infusion of the patient with 4% dextrose may have exacerbated the rise in blood sugars. Besides, non-adherence to the diabetic diet is a major contributor to rising in blood sugars (Rebeiro, et al. 2013; p. 308). When the people with type II diabetes eats food with rich in sugar, their body is unable to convert it to glycogen, hence their blood glucose level will rise. Similarly, non-adherences to the drug regimen are crucial for these people. When they fail to take the drugs as prescribed, their body fails to regulate the blood sugars, therefore, an increase in blood glucose in the body (Rebeiro, et al 2013; p. 308). On the other hand, infusion of normal saline is appropriate. Normal saline expands the blood volume causing the diluting effect of blood (Kable & Bourgeois 2014; p. 61). As a result, the body will be supplied with adequate sugar. Besides, it prevents blood viscosity and reduces the polydipsia effect that is experienced by the patient (Rebeiro, et al. 2013; p. 308). Finally, the insulin infusion corrects the glucose level. In type II diabetes mellitus, oral hypoglycemics are encouraged. However, when sugars surge over the normal, insulin infusion forms a quick remedy from the progression o to diabetic ketoacidosis. From the information above, Mrs. Langerhans is at risk for HHNS, which is a life threatening condition. As she has T2DM, she is not at risk for DKA. Rationale The rationale for this is that, HHNS is likely to develop in diabetes mellitus type II patient if they fail to control the blood sugars. It is more prevalent in individuals with type II than type I (Rebeiro, et al. 2013; p. 308). With high glucose in the body, the intracellular is highly concentrated this cause blood to draw body fluid from other body parts to achieve an osmotic equilibrium that cam be life threatening. Besides being a type II, it is possible to develop diabetic ketoacidosis (Rebeiro, et al. 2013; p. 308). This is because with elevated glucose, the body shifts to ketone bodies as body fuels. This result to accumulation of the ketone acids in the body causing the DKA this can be present in both type I and II. Therefore, it is incorrect to rationalize that since she is type II she cannot develop DKA (Rebeiro, et al. 2013; p. 308). Mrs. Langerhans’s diagnoses on discharge will include T1DM, as she would now be classified as insulin dependent. Rationale This classification as type I diabetic is correct. The rationale for this is that type I insulin is for those patients that are insulin dependent CASE II Mr. Nexium returned to the ward following a hemicolectomy with IVT at 84mL/hr., a large bore NGT insitu and morphine infusion running at 3mg/hr. He is ordered Metoclopramide or tropisetron PRN for nausea. There has been no NGT drainage for three hrs. In addition, Mr. Nexium is complaining of nausea and ultimately vomits 400mL when lying flat. Rationale In the prevention of post-surgical nausea, administration of metoclopramide is a correct intervention. Besides, metoclopramide is the recommended in cases of post-operative nausea and vomiting (Laws 2012; p. 1052). The rationale for this is that, Metoclopramide acts at to inhibit the cholinergic smooth muscle stimulation by activation of the dopamine receptors in these muscles (Rebeiro, et al. 2013; p. 304). In this they increase the amplitude of the peristaltic wave, increase the lower esophageal pressure to enhance the gastric emptying with no effect on the small intestine or colon. Besides, they also block the dopamine receptors in the chemoreceptor trigger zone of the medulla therefore causing ant nausea and antiemetic action (Rebeiro, et al. 2013; p. 304). The RN administers Mr. Nexium IV Metoclopramide, which is always the first anti-emetic administered according to most post-operative nausea and vomiting protocols. The rationale she provides for the administration of IV Metoclopramide is that this will counteract the decreased gastric motility caused by morphine. It is incorrect that metoclopramide will counteract the effect of morphine. The rationale for this is that, Morphine is a central acting opioid analgesic that has a relaxing effect. However, it is not the primary cause of the post-surgical nausea. On the other hand, rather than morphine has a relaxing effect on the smooth muscles rather than the contracting effect (Rebeiro, et al. 2013; p. 304). Furthermore, it has no effect or has less effect on the gastric motility. The RN plans to check the patency of the NGT after 1 hr. if the nausea does not resolve by aspiration with a Toomey syringe and testing the aspirate with litmus paper or pH strips; if no aspirate then instil and immediately aspirate 20mL of sterile water or instil 20mL of air into the NGT and listen for the 'swooshing' of air over the stomach with a stethoscope Rationale The rationale for Checking of the patency of the nasogastric tube after every one hour is because it helps to know draining is taking place (Kable & Bourgeois 2014; p. 70). A period of one hour is sufficient taking into account of the time that it will take for the gasses and fluids to build up therefore causing obstruction. This period is also enough to detect and correct any complications that will occur like obstruction. Aspiration provides a way to know the content of the stomach. The use of the PH or litmus paper is to test for the acidity or alkalinity of the stomach, which is an important determinant of the amount of gastric juice produced (Kable & Bourgeois 2014; p. 70). Testing with water and air is to determine whether the nasogastric tubing is in situ (Rebeiro, et al. 2013; p. 305). However, the intervention of testing with water is not appropriate because if the nasogastric tube has entered the bronchial route it may cause choking that may be very severe (Rebeiro, et al 2013; p. 305). Therefore, this should be avoided. Either this should be the first intervention before doing the other interventions Even though the patient is not having any oral fluids you would expect around 50mL of fluid to build up in the stomach every hour. There may be fluids in the stomach even without feeding. The rationale for this is that, the normal body physiological processes continue. These include salivation and gastric juice secretion. Normally there is secretion of saliva at about 20 millimeters per hour and 30 millimeters of gastric juice (Rebeiro, et al. 2013; p. 305). This, therefore, accounts for the 50 millimeters of the fluid that built up in the stomach. Case III Mrs. Barker, 66 years of age, with a history of HF and DMT2 was admitted to hospital with a 3-day history of nausea and vomiting, increasing abdominal distension and intermittent abdominal pain. Underwent hemicolectomy 3 days previously Clinical data in the table below suggests that: 24hrs post operatively Mrs. Barker is hypovolemic and has lost significant amount of fluid. Such losses could be internal (hemorrhage, 1st phase third space fluid shift) and external (hemorrhage, insensible loss). The rationale for this is that, hypervolemia is a common finding after surgery owing to a lot of blood lost during surgery. Besides, there is a lot of fluid loss and imbalances. However, little of such fluid is internal (Laws 2012; p. 1053). Therefore, the rationale that the fluid loss is internal is incorrect. Even though hemorrhage occurs, it is mostly external and less likely to be internal (Laws 2012; p. 1053). However, post-surgical it is possible for the fluid to be internal due to bleeding tendencies accompanied by the shift of fluids from the extracellular space to the intracellular space caused by hemo concentration of the fluid (Laws 2012; p. 1054). This can be explained by the weight loss seen in the patient post-surgical. 24hrs post operatively Mrs. Barker will require a MET call and should be administered a colloid fluid challenge Rationale After 24 hours, Medical emergency team call is not necessary. The rationale for this is that, the patient is stabilizing with the vitals being stable. Even though, the patient's kidney is not picking up it is because of the less fluid in the body this needs a standard intervention to restore its function. However, the intervention of a colloid is appropriate to prevent fluid shift with the increased fluid in the body. The colloid will prevent a fluid shift to the extracellular thereby preventing the formation of edema (Kable & Bourgeois 2014; p. 70). 72 hrs. Post operatively Mrs. Barker has acute kidney failure, which has resulted in hypervolemia and anemia.  The rate of her IV fluids should be decreased. Rationale After 72 hours, there is little output, and the fluid is accumulating in the body, which is indicative of the body being unable to eliminate the water. However, the amount of urine output is 150mls per hour; this does not meet the criteria to be classified as acute kidney failure. For acute kidney failure, the amount of urine output is or less than 30milimtres per hour (Laws 2012; p. 1051). In this case, many other factors are responsible for the accumulation of the fluids in the body. For example, the fluid input was previously set at 125 millimeters per hour against the body ability to eliminate the fluid from the body as the kidneys were eliminating at a rate of 10 millimeters per second. Therefore, the hypervolemia may be a result of previous fluid overload. Secondly, the rationale that anemia is as a result of kidney failure is incorrect. First, there is no sign of kidney failure. The anemia seen, in this case, is a physiological anemia that occurs because of fluid overload. When there is fluid overload in the body, the blood is over diluted in a phenomenon known as hemodilution that will present as anemia even if there are enough red blood cells because of blood volume expansion (Rebeiro, et al. 2013; p. 304). In kidney failure, additional fluids in the body will lead to fluid overload, therefore, discouraged. However, in this case, the kidneys are picking up to eliminate the excess fluid. Therefore, it is incorrect to limit fluid intake. References Laws, T 2012, chapter 38 ‘Perioperative nursing’, in Cozier and Erg’s Fundamentals of nursing, vol. 2, 2nd end, Pearson Australia, pp. 1044-1086. Rebeiro, G, Jack, L, Scully, N & Wilson, D 2013, ‘Acute care’, in Fundamentals of nursing—clinical skills workbook, 2nd end, Chatswood NSW, Elsevier, pp. 302-307. Kable, A & Bourgeois, S 2014, Chapter 4 ‘Nursing care of people having surgery’, in Medical-surgical nursing—critical thinking for person-centred care, vol. 1, 2nd end, Pearson Australia, pp. 59-89. Read More